GW1--07502_Well Construction - GW1_20231120

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
/16, sii•J'itt,,J A/f0 wt.; M.WA'TEB.ZONES. -_ _ -
Well Contractor Name PROM TO DESCRIPTION y
ft. ft
3t; 3 rAj 1' J
NC Well Contractor Certification Number d 37 ft ��ft do
i 15::OUTER'CAS (fii ING niiulJti;iars'ed wells)ORLII!IER(irk) livable) -
Yadkin Well Company, Inc. FROM • TO DL4METER THICKNESS J MATERIAL
ft ft
Company Name
��� '".I6Il�IEItCASING:ORTUB .G:(geotherrtialcloaed-loop] _ :,._s.:.;l:.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) 4 I ft. SS' ft 7// in. 0,`.;O"/ !�,P ha/.GK si
ww
3.Well Use(check well use): ft. ft in.
Water Supply Well: Z17'SCREY.N
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in. .
❑Geothermal(Heating/Cooling Supply) , tesidential Water Supply(single) �/ t ft
❑lnduslrial/Commercial ❑Residential Water Supply(shared) :iB.,GROUT - `-.- "
❑Isigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT Damon&AMOUNT
Non-Water Supply Well: 4 ft• eQ f ft :68c,��th f'r a , 4v r17 /7
OMonitoring ❑Recovery ft. ft
Injection Well: ft. R
❑Aquifer Recharge ❑Groundwater Remediatioa 19:SAND/GRAVEL PACK(if applicable) --
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑StonnwaterDrainage ft _ ft
[Experimental Technology ❑Subsidence Control ✓ t.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG Which idditlonal'slieets if necessary) — - "-
0 Geothermal(Heating/CoolingReturn) 0 Other(explain under#21 Remarks) FROM TO DESCRDIION(color,hardnemsalllraektypegainviaete)
Date Well Started /0-A I- I% A A/� ® 0 ft /0 ft ....52, f — 1 of/d 's •
4.Date Well(s)Completed:1, ,Cf-Z 3 Well ID# AM" ®3 y ,0 ft L 8 ft Wc.11 .0/ £ 4/B s' 6 6.p ,,M.1 (arvi
. - Sa.WelllLocation: Phone#: g" ® 7g! it. 3ZZ ft /MU/ eir� toeansi.�
gk.L �t �e'1r[Owl. ft. ft. -
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Facility/OwnerName Facility DM(if applicable) ft ft
6 711 Globe, ft Le.A.o ft. ft NOV 0 1023
Physical Address,City,and Zip ft ft.
Ca,
,,I d iArte Li I 21.REMARKS - - -- -- . -.n «...
County Parcel Identification No.(PIN) a Pie- drittC.a, r� /A(relic, `� J 7 7 fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3�,° L e 3'6" N ZD® LI 11 33" w
6.Is(are)the well(s): ermanent or OTemporary igoatureofCertifiedWellContractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ['Yes or tkle ISA NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#2l remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
• construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 2 (ft.)
Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths(different(example-3@200'and 2@100) r
+ I I �i/goat., 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: i3 t(it.
Iffwate level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
II � 24b.For Injection Wells:Copy to
11.Borehole diameter: (9 (in.)glt Off:�T `B{� DWR,Underground Injection Control(lUC)
e Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ah r (0 ' th P v 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) f county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: l^,gr co r Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: 7—ZI- 23
13b.Disinfection type: _ Amount: � OZ Site Visited By: AtAti-
Form GW-1 North Carolina Department of Environmental Quality-,Division of Water Resources Revised 6-6-2018
Price: 5Le cp..*rac,+